Shropshire Birth Centre Closures – Making a Mockery of Consultation

“One of the great strengths of this country is that we have an NHS that – at its best – is of the people, by the people and for the people…we need to engage with communities and citizens in new ways, involving them directly in decisions about the future of health and care services.” (NHS Five Year Forward View) (1)

Shrewsbury and Telford Hospital NHS Trust (SaTH) are repeatedly closing the Ludlow Birth Centre, as well as the Bridgnorth and Oswestry Birth Centres. The closures – for between 12 hours and several weeks – happen without notice, and seem to be stepping stones towards permanent closure. This is a rural area, with long distances to travel from scattered homes to hospital, meaning that the Shropshire MLUs are essential services for the entire maternity journey, providing antenatal, birth and postnatal support to women and their babies without them having to make long, expensive and stressful journeys.

Maternity services are the most commonly used health (as opposed to illness) services provided by the NHS, and they need to be treated like all heavily used services – easy access in the place where people are living. We are not asked to travel to hospital to see the GP or a dentist, and rightly so, as to do so would lead to stress, costs and hospital acquired infections. Yet pregnant women, whose immunity is already lowered by the natural effects of pregnancy, are being asked to travel for miles for regular midwifery appointments and expose themselves and their babies to dangerous bugs. Public transport is very poor, and in some places non-existent. With no local point of contact for midwives, the other option is for midwives to spend hours driving to women to do home visits. New proposals from Shropshire CCG will resolve this issue by simply cancelling postnatal support at home! Meanwhile, SaTH is already reducing access to antenatal and postnatal care during periods of MLU closure.

For some women, the direct effect of this situation is that they are unable to access care, and this disproportionately affects low income women –  a huge irony given that the NHS was created in huge part to ensure that everyone, no matter their financial position, can receive medical attention. “Free at the point of care” is of no use to those who cannot reach the point of care. Some women limit the number of antenatal appointments that they go to, as getting to them is just too hard. Others are unable to travel to hospital during labour, or the midwife is unable to travel to them – so women end up birthing at home without a midwife present. There have been five BBAs in Ludlow alone since May last year. Postnatally, parents who do not have the resources to reach hospital out of hours and who are worried about what may (or may not be) a mild issue with themselves or their baby are waiting until the buses are running again, with the risk that what seems to be minor was actually very serious.

Closing the regional Midwife Led Units means that women and their babies are being put at risk. Women NEED the regional MLUs to be able to access the care that they need. MLUs are safer for women and babies who are at low risk of complications (2) and MLUs are suitable for all women to access routine midwifery care before and after birth.

SaTH claim that they have consulted on some (but not all) of the closures, and claim too that women prefer to birth in hospital, but this is simply untrue. Their strategy has been to regularly close the MLUs, leaving women no choice but to “choose” hospital birth. In fact, engagement carried out by Shropshire CCG found:

“During the engagement work of the CCG, rural women have been adamant that their MLUs are needed and must remain.

Women say they need to reach their intended place of birth quickly and easily. This is to be ended.

Women say they value being cared for by the same midwife, or one of a team of midwives, through antenatal care, birth and postnatal care. This will go, as rural women are to be required to give birth in an unfamiliar setting with staff they do not know.

Women have repeatedly praised the postnatal care available in rural MLUs, and this has been recognised by the CCG as ‘exceptional’. This, too, is to end.” (Shropshire Women Speak Out) (3)

Women and their babies are being put at significant risk of harm, and we call upon the CCG and Trust to implement the directives of Better Births, as well as fulfilling their obligations to providing safe care, by re-opening and supporting the Midwifery Led Units across Shropshire.








What makes a birth centre?

I’ve been privileged to talk to two women who were central to making the Bradford Birth Centre so successful. Alison Brown has recently retired as consultant midwife in normality and Deborah Hughes was project lead in setting up the birth centre. They’ve both moved on and would like to share their experience of enabling natural birth within the NHS in the kind of “alongside midwife unit” encouraged in the new NICE guidelines on low risk birth.

The Bradford Birth Centre now deals with a third of Bradford’s births – around 2000 every year – and offers an environment for a genuinely woman-centred natural birth. It’s taken hard work and a lot of determination after decades of only having an obstetric led unit. But it can work and it does work, so here is the journey that these pioneers took Bradford on.

More than procurement

Both midwives were clear that you need more than the right equipment. As Alison says, “Before the birth centre, we had a pool and it was part of the wider maternity ward but we had a terrible struggle getting midwives to use it… Once it was part of the centre you couldn’t stop them.”

We’ve got a great idea!

At the start, finding allies was key. Who can stand up for the aim of woman-centred birth through the organisation? Deborah says that “having other people keeping an eye on it and championing it” helps an idea grow.

One key ally was Ruth Weston, then Chair of the MSLC, who was able to deal with stumbling blocks and maintain pressure by writing letters and asking questions in a public forum like the Trust AGM.

Even now, the centre benefits from having allies, as community midwives spread the word about the centre, the benefits of their approach and how best to access it.

Creating a confident team

Midwives who were used to labour ward practices benefited from training on natural birth, traditional midwifery skills, alternative pain relief like hot compresses and the role of Oxytocin. They looked again at the language they could use to encourage natural birth. Gradually a group of people committed to a new way of working and a different culture of birth emerged.

Culture is a word that Deborah and Alison keep coming back to. And of course with staff changes, building that culture isn’t a one time job. New midwives work closely with experienced staff. One new midwife told Alison that she felt anxious using water: ‘I can’t see the baby’s head coming out and I don’t want to pass my anxiety onto the mum’. She felt able to tell someone and wanted to deal with her anxiety rather than restrict the options of the women she was working with. That’s the power of a new culture. That midwife received training and even paid for it herself.

A kind culture

Deborah praises Birth Centre Manager Carol Dyson for working on the idea that a different culture meant staff being accessible, kind and warm hearted. Kindness, as Deborah calls it “the gentle stuff”, works right through their practices. Birthing women and staff mingle together, with the whole space open and mixed.

That attention to mood helps women to feel safe and trust the staff. In an age where women often doubt their ability to birth and presume they’ll need a lot of intervention, it takes trust to believe someone saying that rather than having an epidural straight away, try the pool first.

“It’s really sad,” says Alison. “They presume that having a baby is such a risky thing that they’d never be able to do it without lots of intervention and help. We need to give women the confidence that they can have a baby.” And yet, “if you get them in the pool they take a sigh of relief, it lowers the stress in the whole room. You can see the birth hormones kick in and they let things go a little. It relaxes everyone. It’s amazing when you see it.”

Using the space as a whole

As the centre was a small space – seven rooms off a main corridor – one of the key decisions that made it work was using the space as a whole rather than keeping rooms and women separated.

Deborah used her experience from working in Calderdale. Using the space in this way means that the pools can be in constant use and more women can access the centre. “Women can move around and use it how they wish rather than being stuck in one space. Wanting one space tends to be a safety issue and when women feel the space belongs to them and is safe, they don’t mind moving around the whole unit.” A woman moving from a pool to a bed to a sofa is a normal part of birth in the centre.

It meant that while there are only two pools in place, 30 per cent of women give birth in them, with many more moving in and out during their time there.

Policies that stick

Policies take a long time to agree and can be a frustrating part of the process, but both Deborah and Alison emphasise how important they are. Deborah said, “It took over a year. It was very important that everyone knew from the beginning what was going to happen. There were things that we were willing to be flexible on that we had to define so that other people were comfortable.”

They talk about three key steps:

Firstly you need to set out your goal. For the birth centre, the goal was creating the right environment for woman centred natural birth. Everything else was judged against that goal.

Secondly there’s no way to dodge difficult decisions. The team in Bradford decided that women who transferred to the labour ward wouldn’t have continuity of care – the midwife wouldn’t move across with them – because losing staff would make the centre unviable and would stop another woman from taking her place. Continuity of care is rightly important, but they had to consider the hard case of whether it had priority over their main goal.

They couldn’t get agreement to allow access for women who wanted a vaginal birth after a C-section (VBAC). Deborah said “You don’t want any mistakes, heroics or drama”: it felt more important to get agreement and then revisit policies when they could.

Thirdly, there are other parts of the organisation with concerns and the ability to stall progress. In Bradford, after the concerns of the Estates team had been worked through, there was a long running issue with the Moving and Handling Team who insisted on the centre using hoists when getting in and out of the pool. Alison said “We even had people just coming in saying that they’ve come to measure for a hoist! We’ve had to bar the door! We set up a plan for anyone who did collapse in the pool, it works well and we don’t need a hoist. However it’s just part of the problem that the NHS organisation just does not get water birth. We’ve had a similar battle with infection control”.

Who’s the gatekeeper?

The team fought a long time for the principle that women should judge when to access the centre. Deborah says that experience from past work suggested that this was vital to meet their goal. Usually a triage team responds to women asking to be admitted and therefore they effectively get to say when labour’s started and whether the woman is ‘allowed’ to come in.

Instead Bradford Birth Centre ensured that women contact them directly. Women get to choose when they want to access the centre and if there isn’t yet space but they want to sit in the soft seating area and have a hot drink that’s fine with the centre staff.

Despite worries that the centre would get ‘bunged up’, it worked well. Instead of a judgement from triage, first contact is the centre’s way to establish relationships and trust in the staff.

However this is sadly an ongoing battle and it’s an example that even with success, you have to keep arguing your case to avoid sliding back.

Separate and different

What may surprise is how strongly both midwives felt about being separate. The way of working and the environment is so different in the centre that the larger organisational culture is quick to take over again. Whether that’s doctors walking through and imposing decisions, midwives picking back up labour ward ways of working because they get ‘taken off’ their centre work for other priorities or triage deciding when labour starts, separation is key to the goal of enabling woman centred natural birth. Just moving to another part of the building from the labour ward has a big impact.

The future

Separation is important right now, but Alison has spent time finding ways to support higher risk women in the labour ward to achieve the same experience as you’d find in the birth centre. “From the woman’s perspective, it doesn’t matter how many complications or risks you have, women still want a nice environment to birth in. The reason they don’t get that is really complicated though. The ward should be recognised for their high rate of vaginal births. But it feels to staff as though they can’t look after people and have them in the pool.”

Despite working through case studies, buying high tech monitoring equipment and having pools in place, the ward isn’t embracing natural birth yet. Can you recreate that birth centre culture in a labour ward? Alison hopes that her successors keep trying.

Alison finishes by saying, “Changing the culture takes time and is a challenge, we had people trying to tell us that women in Bradford won’t want to use a pool! But when they know it’s there they beat the door down, they start to realise that it will work for them and be a great thing for their birth.” With 2000 women passing through each year, that’s a huge impact on women finding out what a good birth can be like.